Optimizing Post-Acute Coronary Syndrome Dyslipidemia Management: Insights from the North American Acute Coronary Syndrome Reflective III.

INTRODUCTION: Despite contemporary practice guidelines, a substantial number of post-acute coronary syndrome (ACS) patients fail to achieve guideline-recommended LDL-C thresholds. Our study aimed to investigate this guideline recommendations-to-practice care gap. Specifically, we aimed to identify opportunities where additional lipid-lowering therapies are indicated and explore reasons for the non-prescription of guideline-recommended therapies. METHODS: ACS patients with LDL-C ≥1.81 mmol/L (70 mg/dL) despite maximally tolerated statin ± ezetimibe therapy (including those intolerant of ≥2 statins) were enrolled 1-12 months post-event from 27 Canadian and US sites from September 2018 to October 2020 and followed up for three visits during the 12 months post-event. We determined the proportion of patients who did not achieve Canadian/US guideline-recommended LDL-C thresholds, the number of patients who would have been eligible for additional lipid-lowering therapies, and reasons behind lack of escalation in lipid-lowering therapies when indicated. Individual patient and aggregate practice feedback, including guideline-recommended intensification suggestions, were provided to each physician. RESULTS: Of the 248 patients enrolled in the pilot study (median age 64 [57, 73] years, 31.5% female and STEMI 27.4%), 75.4% were on high-intensity statins on the first visit. A total of 18.5% of those who attended all 3 visits had an LDL-C measured only at the first visit which was above the threshold. After 1 year of follow-up, 51.9% of patients achieved LDL-C thresholds at either visit 2 or 3. In the context of feedback reminding physicians about guideline-directed LDL-C-modifying therapy in their individual participating patients, we observed an increase in the use of ezetimibe and PCSK9 inhibitor therapy at 3-12 months. This was associated with a significant lowering of the mean LDL-C (from 2.93 mmol/L [baseline] to 2.09 mmol/L [3-6 months] to 1.87 mmol/L [6-12 months]) and a significantly greater proportion of patients (from 0% [baseline] to 38.6% [3-6 months] to 53.4% [6-12 months]) achieving guideline-recommended LDL-C thresholds. The most prevalent reasons behind the non-intensification of LDL-C-lowering therapy with ezetimibe and/or PCSK9i were LDL-C levels being close to target, the pre-existing use of other lipid-lowering therapies, patient refusal, and cost. CONCLUSION: Although most patients post-ACS were on high-intensity statin therapy, almost 50% failed to achieve guideline-recommended LDL-C thresholds by 1-year follow-up. Furthermore, additional lipid-lowering therapies in this high-risk group were underprescribed, and this might be linked to several factors including potential gaps in physician knowledge, treatment inertia, patient refusal, and cost.

Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps?

Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.

Comparing the Effectiveness of 2 Cardiac Rehabilitation Exercise Therapy Programs.

Cardiovascular diseases are among the leading causes of morbidity and mortality in Canada, highlighting the critical role of disease prevention and risk reduction programs. Cardiac rehabilitation (CR) is a key component of comprehensive cardiovascular care. Currently, more than 200 CR programs are established across the country, varying in duration, number of in-person supervised exercise sessions, and recommendations for exercise frequency at-home. In an increasingly cost-conscious healthcare environment, the effectiveness of healthcare services must be consistently reevaluated. This study evaluates the impact of 2 CR programs implemented by the Northern Alberta Cardiac Rehabilitation Program, by comparing peak metabolic equivalents achieved by study participants in each program. We hypothesize that our "hybrid" CR program, which is structured as an 8-week program with weekly in-person exercise sessions and a prescribed home exercise program, has patient outcomes similar to those of our "traditional" CR program, which required biweekly in-person exercise sessions over the course of 5 weeks. The results of this study may have implications for evaluating how to minimize barriers to both rehabilitation participation and long-term effectiveness of CR programs. The results may help inform the structuring and funding of future rehabilitation programs.

Les maladies cardiovasculaires (MCV) sont parmi les premières causes de morbidité et de mortalité au Canada d'où l'importance des programmes de prévention des MCV et de réduction du risque cardiovasculaire. La réadaptation cardiaque est un élément clé du continuum de soins cardiovasculaires. À l'heure actuelle, il existe plus de 200 programmes de réadaptation cardiaque au pays, qui diffèrent tant par leur durée, par le nombre de séances d'exercice supervisées en personne que par leurs recommandations sur la fréquence des exercices à domicile. Dans un contexte où le coût des soins de santé est de plus en plus préoccupant, l'efficience des services de santé doit constamment être réévaluée. Cette étude évalue les effets de deux programmes de réadaptation cardiaque instaurés par le Cardiac Rehabilitation Program du nord de l'Alberta en comparant l'équivalent métabolique maximal obtenu par les participants à l'étude pour chaque programme. L'hypothèse de départ était que notre programme de réadaptation cardiaque « hybride ¼, qui consiste d'une part en un programme de huit semaines de séances hebdomadaires d'exercices en personne et d'autre part en un programme d'exercices à domicile, donnerait des résultats semblables à ceux de notre programme « traditionnel ¼ de réadaptation cardiaque. Celui-ci se compose de deux séances d'exercices en personne par semaine, pendant cinq semaines. Les résultats de cette étude pourraient nous aider à réduire les obstacles qui nuisent à la participation aux programmes de réadaptation et à l'efficience à long terme de ces programmes. Nous espérons apporter un éclairage sur la structure et le financement des futurs programmes de réadaptation.

Participant Exercise-Session Attendance in Community-Based, Bridging, and Hospital-Based Cardiac Rehabilitation: A Retrospective Case-Control Study.

Background: A paucity of studies have investigated participant attendance in community-based and hybrid cardiac rehabilitation programs in the Canadian setting. We compared exercise-session attendance of community-based, bridging (hospital plus community-based), and hospital-based participants who attended a high-volume cardiac rehabilitation program in Alberta, Canada. Methods: Exercise sessions attended and participant characteristics were collected and analyzed from 230 records of patients who attended cardiac rehabilitation between 2016 and 2019. Community-based (n = 74) and bridging (n = 41) program participants were age- and sex-matched in a 1:1 ratio to hospital-based participants. The number of exercise sessions attended was compared among program groups, between female and male patients, and for patients with vs without cardiac surgery. The percentage of exercise sessions attended was also compared among program groups. Results: Bridging participants attended the greatest number of exercise sessions (median = 10.0 sessions) and demonstrated a significantly higher percentage of sessions attended (91%, 25th and 75th percentile interquartile range [IQR] = 64, 100%) than matched hospital participants (median = 6.0 sessions; 63%, 25, 75 IQR = 13, 94%; P = 0.01). Percentage of sessions attended did not differ for bridging and community-based participants (P = 0.30). Exercise-session attendance was similar for community-based participants (median = 6.0 sessions; 75%, 25, 75 IQR = 38%, 88%) vs their hospital matches (median = 6.0 sessions; 81%, 25, 75 IQR = 38%, 100%; P ≥ 0.37), as well as for female vs male patients (median = 7.0 sessions for both sexes; P = 0.66), and for surgical vs nonsurgical patients (median = 7.0 sessions; P = 0.48). Female patients in the bridging program attended significantly more exercise sessions in the community, compared with male patients in the bridging program (P = 0.02). Conclusions: Bridging participants attended the most exercise sessions overall and demonstrated a higher percentage attendance than hospital-based participants. These results suggest that a hybrid program consisting of hospital and community-based exercise was favourable for exercise-session attendance. Given modern approaches to de-medicalize cardiac rehabilitation, our findings further support the provision of community program offerings, without detriment to patient session attendance.

Introduction: Peu d'études ont porté sur la participation des patients aux programmes communautaires ou hydrides de réadaptation cardiaque du Canada. Nous avons comparé la participation des patients aux séances d'entraînement en milieu communautaire, de transition (en milieu hospitalier et milieu communautaire) et en milieu hospitalier d'un programme de réadaptation cardiaque à volume élevé de l'Alberta, au Canada. Méthodes: Nous avons collecté et analysé les données sur les séances d'entraînement suivies et les caractéristiques des participants provenant de 230 dossiers de patients qui avaient participé à la réadaptation cardiaque entre 2016 et 2019. Les participants du programme en milieu communautaire (n = 74) et du programme de transition (n = 41) ont été appariés par âge et sexe aux participants du programme en milieu hospitalier selon un ratio 1:1. Le nombre de séances d'entraînement suivies a été comparé entre les groupes du programme, entre les patientes et les patients, et entre les patients qui avaient subi ou non une chirurgie cardiaque. Le pourcentage des séances d'entraînement suivies a aussi été comparé entre les groupes du programme. Résultats: Les participants du programme de transition ont assisté au plus grand nombre de séances d'entraînement (médiane = 10,0 séances) et ont démontré un pourcentage significativement plus élevé de séances suivies (91 %, 25e et 75e percentile [25, 75] intervalle interquartile [IIQ] = 64, 100 %) que les participants appariés du programme en milieu hospitalier (médiane = 6,0 séances; 63 %, 25, 75 IIQ = 13, 94 %; P = 0,01). Le pourcentage de séances suivies ne différait pas entre les participants du programme de transition et les participants du programme en milieu communautaire (P = 0,30). La participation aux séances d'entraînement était similaire entre les participants du programme en milieu communautaire (médiane = 6,0 séances; 75 %, 25, 75 IIQ = 38 %, 88 %) et les participants appariés du programme en milieu hospitalier (médiane = 6,0 séances; 81 %, 25, 75 IIQ = 38 %, 100 %; P ≥ 0,37), de même qu'entre les patientes et les patients (médiane = 7,0 séances pour les deux sexes; P = 0,66), et les patients opérés et les patients non opérés (médiane = 7,0 séances; P = 0,48). Les patientes du programme de transition ont participé à un nombre plus important de séances d'entraînement en milieu communautaire que les patients du programme de transition (P = 0,02). Conclusions: Les participants du programme de transition ont dans l'ensemble assisté à la plupart des séances d'entraînement et ont démontré un pourcentage plus élevé de participation que les participants du programme en milieu hospitalier. Ces résultats indiquent qu'un programme hybride qui consiste en un entraînement en milieu hospitalier et en milieu communautaire favorisait la participation aux séances d'entraînement. Compte tenu des approches contemporaines de démédicalisation de la réadaptation cardiaque, nos conclusions justifient d'autant plus la mise à disposition de programmes en milieu communautaire, et ce, sans compromettre la participation des patients aux séances.

Physical Activity in Renal Disease and the Effect on Hypertension: A Randomized Controlled Trial.

INTRODUCTION: Exercise is an effective strategy for blood pressure (BP) reduction in the general population, but its efficacy for the management of hypertension in chronic kidney disease (CKD) is not known. We evaluated the difference in 24-h ambulatory systolic BP (SBP) with exercise training in people with moderate to severe CKD. METHODS: Participants with an estimated glomerular filtration rate (eGFR) of 15-44 mL/min per 1.73 m2 and SBP >120 mm Hg were randomized to receive thrice-weekly moderate-intensity aerobic-based exercise over 24 weeks, or usual care. Phase 1 included supervised in-center and home-based sessions for 8 weeks. Phase 2 was 16 weeks of home-based sessions. BP, arterial stiffness, cardiorespiratory fitness, and markers of cardiovascular (CV) risk were analyzed using mixed linear regression. RESULTS: We randomized 44 people; 36% were female, the median age was 69 years, 55% had diabetes, and the median eGFR was 28 mL/min per 1.73 m2. Compared with usual care, there was no significant change in 24-ambulatory SBP at 8 weeks (2.96 mm Hg; 95% confidence interval (CI): -2.56, 8.49) or 24 weeks. Peak oxygen uptake improved by 1.9 mL/kg/min in the exercise group (95% CI: 0.03, 3.79) at 8 weeks with a trend toward higher body mass index 1.84 kg/m2 (95% CI: -0.10, 3.78) and fat free mass, but this was not sustained at 24 weeks. Markers of CV risk were unchanged. CONCLUSIONS: Despite an improvement in peak aerobic capacity and body composition, we did not detect a change in 24-h ambulatory SBP in people with moderate-to-severe CKD.

Rehabilitation Needs in Cancer Treatment-Related Cardiotoxicity.

OBJECTIVES: To examine and summarize current international guidelines regarding cardiovascular risk reduction before and during cancer therapy, and to discuss the emerging role of cardio-oncology as a subspecialty in cancer care and the role of cardio-oncology rehabilitation. DATA SOURCES: Published articles and guidelines. CONCLUSION: With improvements in cancer detection and the use of novel adjuvant therapies, an increasing number of individuals now survive a cancer diagnosis. However, for some the cost is high - many survivors are now at higher risk of death from cardiovascular disease than from recurrent cancer. Cardiovascular morbidity and mortality are common and associated with common cancer therapies serially administered in adult oncology care. IMPLICATIONS FOR NURSING PRACTICE: Timely risk-reduction interventions hold promise in reducing cardiovascular morbidity and mortality. Oncology nurses are the key providers to identify baseline risks, perform necessary referrals, provide individualized teaching, and support the patient within the family and community.

Cardiovascular Efficacy and Safety of PCSK9 Inhibitors: Systematic Review and Meta-analysis Including the ODYSSEY OUTCOMES Trial.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are efficacious lipid-lowering agents, but more precise estimates of their effects on major adverse cardiovascular events (MACE), mortality, and safety are needed. We systematically reviewed and meta-analyzed randomized controlled trials with durations ≥ 6 months comparing MACE, mortality, and safety with PCSK9 inhibitors vs control. We searched CENTRAL, Embase, MedLine and the grey literature to November 7, 2018. From 2048 articles, we included 23 trials (n = 60,723). PCSK9 inhibitors reduced MACE (relative risk, 0.83; 95% confidence interval, 0.78-0.88), but did not clearly reduce mortality (relative risk, 0.93; 95% confidence interval, 0.85-1.02) or increase adverse events. In conclusion, PCSK9 inhibitors reduce nonfatal MACE, are well tolerated, but effects on mortality remain unclear.

Cardiac Rehabilitation in Patients With Lymphoma Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Cardio-oncology Pilot Project.

BACKGROUND: Worldwide > 50,000 hematopoietic stem cell transplants (HSCTs) are performed annually. HSCT patients receive multiple cardiotoxic therapies (chemotherapy and radiation therapy) in addition to severe physical deconditioning during hospital admission. We hypothesized that guided exercise in a cardiac rehabilitation (CR) program following autologous HSCT is a safe and feasible intervention. METHODS: Pilot project to assess for safety, feasibility and impact of 8 weeks of CR in HSCT patients following transplant. Consecutive patients with lymphoma underwent standard activity protocol testing before HSCT, at 6 weeks following HSCT (prior to CR), and at 14 weeks following HSCT (at completion of CR), consisting of grip strength (GS), gait speed (GtS), timed up-and-go (TUG), and 6-minute walk test (6MWT). CR consisted of 8 weekly visits for guided exercise. RESULTS: Activity tolerance protocol data of 30 patients (24 male, 6 female) from December 2014 to December 2016 were analyzed using repeated measures (analysis of variance [ANOVA]) to observe for changes in GS, GtS, TUG, and 6MWT. Statistically significant improvements were found in GS (P < 0.005), GtS (P = 0.02), and 6MWT (P = 0.001). These improvements show that guided CR-based exercise may assist HSCT survivors to meet or even surpass baseline exercise levels and improve physical functioning. There were no adverse events (ie, death or injury) during the study period. Fifty-seven percent of referred patients participated in CR, exceeding documented CR adherence in cardiac populations. CONCLUSIONS: The addition of CR-based exercise programming in HSCT survivorship care of patients with lymphoma is a safe and feasible intervention to assist in recovery following transplant.

GRACE risk score: Sex-based validity of in-hospital mortality prediction in Canadian patients with acute coronary syndrome.

BACKGROUND: Although there are sex differences in management and outcome of acute coronary syndromes (ACS), sex is not a component of Global Registry of Acute Coronary Events (GRACE) risk score (RS) for in-hospital mortality prediction. We sought to determine the prognostic utility of GRACE RS in men and women, and whether its predictive accuracy would be augmented through sex-based modification of its components. METHODS: Canadian men and women enrolled in GRACE and Canadian Registry of Acute Coronary Events were stratified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS). GRACE RS was calculated as per original model. Discrimination and calibration were evaluated using the c-statistic and Hosmer-Lemeshow goodness-of-fit test, respectively. Multivariable logistic regression was undertaken to assess potential interactions of sex with GRACE RS components. RESULTS: For the overall cohort (n=14,422), unadjusted in-hospital mortality rate was higher in women than men (4.5% vs. 3.0%, p<0.001). Overall, GRACE RS c-statistic and goodness-of-fit test p-value were 0.85 (95% CI 0.83-0.87) and 0.11, respectively. While the RS had excellent discrimination for all subgroups (c-statistics >0.80), discrimination was lower for women compared to men with STEMI [0.80 (0.75-0.84) vs. 0.86 (0.82-0.89), respectively, p<0.05]. The goodness-of-fit test showed good calibration for women (p=0.86), but suboptimal for men (p=0.031). No significant interaction was evident between sex and RS components (all p>0.25). CONCLUSIONS: The GRACE RS is a valid predictor of in-hospital mortality for both men and women with ACS. The lack of interaction between sex and RS components suggests that sex-based modification is not required.

The Effect of Nurse Practitioner-Led Intervention in Diabetes Care for Patients Admitted to Cardiology Services.

OBJECTIVE: To determine the benefits of diabetes nurse practitioner (DNP) intervention on glycemic control, quality of life and diabetes treatment satisfaction in patients with type 2 diabetes (T2DM) admitted to cardiology inpatient services at a tertiary centre. PATIENTS AND METHODS: Patients admitted to the cardiology service with T2DM who had suboptimal control (HbA1c >6.5%) were approached for the study. Diabetes care was optimized by the DNP through medication review, patient education and discharge care planning. Glycemic control was evaluated with 3-month post-intervention HbA1c. Secondary outcomes of lipid profiles, quality of life and treatment satisfaction were evaluated at baseline and at 3 months with fasting lipids, Audit of Diabetes-Dependent Quality of Life questionnaires (ADDQoL) and Diabetes Treatment Satisfaction Questionnaires (DTSQ) respectively. RESULTS: With almost 49% of patients admitted to the Mazankowski Alberta Heart Institute having HbA1c <6.5%, only 23 patients completed the study over a 12-month period. We found a significant decrease in HbA1c values at 3 months post-intervention from 8.0% (SD=1. 2) to 6.9% (SD=0.7), p=0.002. LDL showed a significant decrease at 3 months from 1.7 mmol/L (SD=0.7) to 1.1 mmol /L (SD=0.6), p=0.011. Overall median ADDQoL impact scores improved at follow up, from -1.4 to -0.4, p = 0.0003. Overall no significant changes in DTSQ scores were seen. CONCLUSIONS: Short-term DNP intervention in T2DM patients admitted to the inpatient cardiology service was associated with benefits in areas of glycemic control and various domains of QoL. Our study provides support for the involvement of DNP in the care of cardiology inpatients at tertiary centres.

In-hospital management and outcomes of acute coronary syndromes in relation to prior history of heart failure.

INTRODUCTION: The prognostic significance of prior heart failure in acute coronary syndromes has not been well studied. Accordingly, we evaluated the baseline characteristics, management patterns and clinical outcomes in patients with acute coronary syndromes who had prior heart failure. METHODS AND RESULTS: The study population consisted of acute coronary syndrome patients in the Global Registry of Acute Coronary Events, expanded Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events between 1999 and 2008. Of the 13,937 eligible patients (mean age 66±13 years, 33% female and 28.3% with ST-elevation myocardial infarction), 1498 (10.7%) patients had a history of heart failure. Those with prior heart failure tended to be older, female and had lower systolic blood pressure, higher Killip class and creatinine on presentation. Prior heart failure was also associated with significantly worse left ventricular systolic function and lower rates of cardiac catheterization and coronary revascularization. The group with previous heart failure had significantly higher rates of acute decompensated heart failure, cardiogenic shock, myocardial (re)infarction and mortality in hospital. In multivariable analysis, prior heart failure remained an independent predictor of in-hospital mortality (odds ratio 1.48, 95% confidence interval 1.08-2.03, p=0.015). CONCLUSIONS: Prior heart failure was associated with high risk features on presentation and adverse outcomes including higher adjusted in-hospital mortality in acute coronary syndrome patients. However, acute coronary syndrome patients with prior heart failure were less likely to receive evidence-based therapies, suggesting potential opportunities to target more intensive treatment to improve their outcome.

Use and timing of coronary angiography and associated in-hospital outcomes in Canadian non-ST-segment elevation myocardial infarction patients: insights from the Canadian Global Registry of Acute Coronary Events.

BACKGROUND: Although an early invasive approach has become standard strategy for the management of non-ST-segment elevation myocardial infarction (NSTEMI), the frequency and timing in Canada is uncertain. METHODS: We examined the use and timing of coronary angiography, revascularization, and cardiovascular outcomes of NSTEMI patients: (1) admitted on weekdays vs weekends; and (2) stratified according to presentation risk level, in the Canadian Global Registry of Acute Coronary Events (GRACE)/Expanded GRACE (GRACE(2))/Canadian Registry of Acute Coronary Events (CANRACE) population. RESULTS: Of 6711 NSTEMI patients, 1956 (29.1%) were admitted on the weekend. The median (interquartile range) wait time for coronary angiography was 58 (32-106) and 70 (50-112) hours for weekday and weekend patients, respectively (P = 0.32). Compared with lower-intermediate risk, higher-risk patients were less likely to undergo angiography (44.7% vs 69.7% for weekdays and 45.2% vs 69.6% for weekends; both P < 0.0001) and waited longer for angiography (median 71 vs 61 hours; P < 0.0001). Weekend admission was independently associated with higher mortality (adjusted odds ratio [OR], 1.52; 95% confidence interval [CI], 1.15-2.01; P = 0.004), recurrent ischemia (adjusted OR, 1.16; 95% CI, 1.01-1.32; P = 0.03), and heart failure (adjusted OR, 1.28; 95% CI, 1.00-1.63; P = 0.048) but not with reinfarction. CONCLUSIONS: Median wait time for angiography in Canadian NSTEMI patients admitted on the weekend was not significantly longer than for those who presented on a weekday. Patients admitted on weekends had higher adjusted mortality and cardiovascular event rates. Higher-risk patients were less likely to undergo angiography and waited longer, with higher observed in-hospital event rates. Systematic, guideline-recommended risk stratification should be considered to ensure that optimal management strategies (eg, timely coronary angiography in higher-risk patients) are matched to level of risk.

The clinical effect and tolerability of ezetimibe in high-risk patients managed in a specialty cardiovascular risk reduction clinic.

INTRODUCTION: Ezetimibe (EZ) is a selective cholesterol absorption inhibitor approved for use in Canada. The effect and tolerability of EZ among patients was evaluated in the clinical setting of a specialty cardiovascular risk reduction clinic at the University of Alberta Hospital, Edmonton, Alberta. patients and METHODS: All patients 18 years of age or older who were prescribed EZ were included, unless they failed to take EZ for a minimum of two weeks, did not have baseline and on-EZ low-density lipoprotein cholesterol (LDL-C) levels, or had concomitant lipid-lowering drugs or dosages changed within one month of starting EZ. RESULTS: Eighty-four patients (mean age 57.9 years) were included. By Framingham risk calculation, 71.4% were found to be high-risk patients, 13.1% moderate-risk patients and 15.5% low-risk patients; 66.7% of patients had prior cardiovascular events. On EZ, the mean reductions were: total cholesterol level 1.11 mmol/L (16.5%); LDL-C level 1.01 mmol/L (22.3%); high-density lipoprotein cholesterol level 0.06 mmol/L (4.6%); and ratio of total cholesterol level to high-density lipoprotein cholesterol level 0.68 mmol/L (12.8%); all were statistically significant (P<0.001). Results were similar when stratified by primary (n=28) versus secondary (n=56) prevention. Patients on EZ monotherapy (n=34) had mean LDL-C reductions of 1.03 mmol/L (20.5%) compared with 1.19 mmol/L (30.1%) or 0.95 mmol/L (22.5%), where EZ was added to low-dose or high-dose statins (P<0.01 for all). On EZ, 30 patients (35.7%) achieved previously unattainable target LDL-C levels. Four patients discontinued the drug due to side effects. CONCLUSIONS: EZ is safe and effective in high-risk patients treated in the clinical setting of a cardiovascular risk reduction clinic. A mean LDL-C reduction of 1 mmol/L (20% to 30%) in all patient subgroups is consistent with previous clinical trial results. The significant reduction in LDL-C (mean 22.5%) observed in the EZ plus high-dose statin subgroup provides clinical evidence for use of this medication beyond published studies.